We’ve never really seen a man or an elephant in long term ketosis before . . .
“It’s a snake.”
“It’s a wall.”
“It’s a rope.”
“It’s a fan.”
“It’s a tree.”
“It’s insulin resistance.”
I’ve always been fascinated by those describing a “new finding” in medicine. I am reminded of the story of 5 men who, never having seen an elephant before, were blindfolded and asked to describe what he discovered. However, each man was introduced to a different part of the elephant. Each of them had a dramatically different description of the elephant and each made a conclusion that was very different from the others.
What is fascinating, is that we usually make our “blindfolded comparisons” to those things we have seen or about which we have some descriptive understanding. Observing and describing human physiology is much like examining an elephant while blindfolded for the first time.
This week’s “blind-folded finding” is what has been interpreted by some as “insulin resistance” made worse by a ketogenic diet. Really? This perked my curiosity, because I’ve personally been following a low-carbohydrate/ketogenic diet for years and have thousands of patients doing the same. To this day, I’ve never seen insulin resistance “get worse.” In fact, it gets better. Clinically, it seems to take about 18-24 months to improve, but, it usually gets better.
THE QUESTION –
I’ve had three people from around the world contact me this week and ask why, after being on a ketogenic diet and “in ketosis,” they suddenly get a notably large blood glucose spike when they cheat. By notably large, I mean that their blood sugars rise to over 200 mg/dl within 2 hours of a carbohydrate containing meal. Now, they admit to rapid glucose recovery within an hour or two, and their hemoglobin A1c levels are subjectively normal (less than 5.6%). The worry is “am I becoming diabetic?” They also complain that after having been in ketosis for longer than 3-4 months, they cannot get their fasting blood sugars below 100 mg/dl.
Those asking me the question about this anomalous “physiological insulin resistance” referred to a couple of off-the-cuff blogger’s posts from 2-3 years ago referencing a few small studies (some of which were very poorly designed) [here, here, here & here] in the journals from 10-20 years ago. These articles describe a physiologic response interpreted as worsening “insulin resistance.” However, if you understand what is actually occurring in the Ketonian (yes, I made that term up – there will soon be a whole village of us), I see it as a normal physiologic response. It is misinterpreted by those who’ve never actually seen long term ketogenic physiology, as anomalous, in the average human.
THE ANSWER –
I’ve been seeing this slight elevation in fasting blood sugar with normal or low normal HbA1c in myself and many of my patients for quite some time. However, I never saw it as “insulin resistance” worsening. Clinically, when I tease out the food logs, it usually ends up being protein intake is too high, the person is using a sweetener or creamer causing rebound morning glucose elevation or, in those with low normal HbA1c’s (4.3-5.6%), it is in actuality a protective mechanism of “physiologic glucose sparing” in the keto-adapted individual (1, 2).
It can very easily be explained when one understands how ketones are actually used in the keto-adapted individual. First, a wonderful figure below (Thank you for pointing me to this one, Dr. Peter Attia) found in Dr. Veech et. al.’s paper (3) gives us an overview of how ketones skirt the TCA cycle within the mitochondria of the cell, causing inhibition of pyruvate dehydrogenase leading to glucose sparing by the cells of the brain that still require it’s availability (Oh, by the way, this is how we survived harsh winters and famines).
From the Figure 1 above, you can see that beta-hydroxybuterate [BHB (a ketone)] is converted to acetoacetyl CoA leading to the production of pyruvate, block-aiding additional glycolysis or inhibiting further glucose production at the liver level. Because the muscle tissues become more adept at using BHB, GLUT receptors are down-regulated at the muscle level as a person becomes more keto-adapted. Although we still have much to learn about the keto-adapted state, we know that this occurs more prominently in the muscle tissues than in the gut and brain. This fascinating glucose sparing phenomenon, has been interpreted by some as “worsening insulin resistance.”
Not to worry, glucose sparing is rapidly reversible and transitory within 1-3 days of increasing carbohydrate intake above 100-150 grams per day (1). It is also why those who become keto-adapted get a carbohydrate hangover including headache, stomach cramps, diarrhea, and malaise lasting 8-24 hours after cheating.
Is this bad? Absolutely not! It is NORMAL! (It’s just that most people, physicians included don’t know what the normal physiology of the Ketonian should look like.) Is it going to kill you, cause a stroke or give you a heart attack? Absolutely not. The elevated BHB actually increases production of adiponectin, leucine & glutathione that have antioxidant properties protecting one from transient inflammatory rises in blood sugar, enhancing insulin’s effect on the muscle, and preserving muscle mass while allowing for fat metabolism (4, 5, 6).
THE TAKE-HOME MESSAGE –
First, don’t cheat if you don’t want to see transient rises in blood sugar and experience the wonders of a carbohydrate hangover and some mild reactive hypoglycemia (low blood sugar) after the fact.
Second, if you’ve been in ketosis for longer than 3-4 months, and you absolutely must get another two or three hour oral glucose tolerance test (OGTT), you might want to increase your carbohydrate intake to 50-100 grams per day 1-3 days before the test to avoid an anomalous spike in blood glucose. (One OGTT was enough for me . . . but hey, some of us are gluttons for punishment.)
Third, enjoy your eggs, pass the bacon and stir me up some Keto//OS.
KetoOS – Drinkable Exogenous Ketones
References:
Kinzig KP, Honors MA, Hargrave SL. Insulin sensitivity and glucose tolerance are altered by maintenance on a ketogenic diet. Endocrinology 151: 3105–3114, 2010.
Oliveira Caminhotto R, Lima FB. Impaired glucose tollerance in low-carbohydrate diet: maybe only a physiological state. American Journal of Physiology – Endocrinology and Metabolism Published 15 December 2013 Vol. 305 no. 12, E1521 DOI: 10.1152/ajpendo.00580.2013
Veech RL, Chance B, Kashiwaya Y, Lardy HA, Cahill GF Jr. Ketone bodies, potential therapeutic uses. IUBMB Life. 2001 Apr;51(4):241-7.
Join me as we chew the phat of ketogenic lifestyles PeriScope style and answer many questions like, “Why do I get ‘hangry’?” What causes hypoglycemia? How many times a day should I eat? and many more . . .
We talk briefly about why 60% of people with insulin resistance may need methylated folic acid to help with B vitamin absorption/use and where it can be found. (See me recent article about this called The Power of a Good Vitamin.)
You can see the whole PeriScope conversation on Katch.me/docmuscles with the comments scrolling or you can see the video stream below:
There are three constants in life: change, choice & principles. Change, ironically acting as a constant, is the variable that we have limited control over. Accepting that change is going to happen, that change is constant, and making choices to prepare for those changes is the key to success. My last post introduced the 10 Principles of the Ketogenic Lifestyle. This post will discuss choice as a foundation for those principles outlined in the ketogenic lifestyle. Choices are directly influenced by the balance between the mind, the body and the spirit of man.
LIFESTYLE PRINCIPLE 1 – WHEREVER YOU GO, THERE YOU ARE
People seem to get sidetracked off a ketogenic lifestyle for a number of reasons, but the most common I hear is that they were traveling, had company visit or they were on vacation. Successfully living a lifestyle requires that you first know who you are and where you are before you can consistently make good, solid, principle based choices. So I ask, who are you? Are you defined by your job, by your finances, by your travels, by your friends or by your vacations? Each of these experiences is unique. Our experiences place both good and bad before us. I have come to learn over time and countless interactions with people that nothing is coincidental. Everything, good and bad, happen for a reason.
Today’s society teaches the Pleasure Principle. This is the human instinct to seek pleasure and avoid pain, including avoiding painful recollections. We often define ourselves by those things that bring us pleasure. We each go through personal tests, failures and triumphs. Some of us harness all of those experiences for good, others find worsening mental paralysis due to fear of them. We often hide from the painful experiences and attempt to bury or forget them. Food is often involved with many of the experiences of life, and for a significant number of people, the endorphin release from eating a meal, sometimes just the act of chewing, may be the only pleasure one experience in a day, in a week or a in a year. Many people hide from painful recollections behind the simple pleasure produced by the eating of “comfort foods.” Food, and our opportunities to experience pleasure from it’s various flavors, textures and physical stimulus, begin to define us. However, hiding from life’s painful memories with momentary pleasures usually prolongs or makes the problem worse. The ingestion of simple foods containing glucose and fructose, their effect on the liver, and the hedonistic hormonal response is the basis of addiction, and simple carbohydrates provide the perfect fix.
Fascinatingly, when fructose is metabolized in the liver, in the presence of glucose (the basic structure of sugar – one fructose molecule bound to a glucose molecule), the byproduct has a hedonic (pleasure experiencing) effect on the exact same pleasure receptors in the brain that bind to morphine. Yes, that’s why the M&M’s make you forget your troubles and why the Jolly Rancher is so jolly. And, its the same reason you crave another do-nut two hours after you ate the entire baker’s dozen.
Although obesity has been recognized as a disease, our use of foods to celebrate with people or events in life is still a form of pleasure seeking. Excuses to deviate from healthy behavior under the guise of family, vacation, or social requirements, acknowledges our willingness to hide from pain with hedonic drugs like chocolate chip cookies and cotton candy. In fact, it’s usually a welcomed and and expected acceptable excuse.
“Dr. Nally, I can cheat eat and bad, (meals loaded with starch) because I’m on vacation” . . . from my problems. It’s so acceptable, we’ve based movie themes around it.
Healing can only occur when one is willing to confront and talk about the reasons, the real reasons you’d rather experience the endorphins from the do-nuts with your family instead of acknowledge your weakness, stresses, and fears. Many of us are so afraid of where we might be, we avoid acknowledging where and who we are. It takes courage not to take the easy path. And I will be the first to admit, pizza is the easy path and it’s scenic views are decorated with french fry palms and sunset clouds of apple fritters.
“There appears to be a conscience in mankind which severely punishes the man who does not somehow and at some time, at whatever cost to his pride, cease to defend and assert himself, and instead confess himself fallible and human. Until he can do this, an impenetrable wall shuts him out from the living experience of feeling himself a man among men. Here we find a key to the great significance of true, un-stereotyped confession – a significance known in all the initiation and mystery cults of the ancient world, as is shown by a saying from the Greek mysteries: “Give up what thou hast, and thou will receive.” (Carl Jung)
We have a choice about what to eat and when to eat, however, each choice has a reward and/or a consequence.
Points of Focus: Where are you and what are you hiding from? Sharing your weaknesses actually empowers you you overcome them. This can often be accomplished through the simple act of journaling, planing your meals the day before and journaling your successes and failures in that plan the following day. Allowing yourself and others insight into your times of weakness actually brings strength. It allows one to look at the reasons for food choices base on how you feel, and how you felt after the choice. If forces one to think about a choice before it ever has to be made. In my 15 years of medical practice, I have yet to hear a child find fault with a parent who worked tirelessly to make ends meet, admittedly struggled with alcoholism, battled against disease or fought against belittling for a belief. The child has always expressed their admiration of their parent’s courage and understanding of why decisions were made, even when erroneous. It takes courage to admit that wherever you go – there you are.
LIFESTYLE PRINCIPLE 2 – KEEP IT REAL
I no longer believe in coincidence. Whether you have thought about it or not, every interaction you have with others (even our interaction . . . your reading this blog), are not by coincidence. There is a reason. Whether you believe it or not, everything around us testifies that God exists; the Hand of Providence can be seen from the rotation of the earth, planets and stars, the precision of the seasons, the balance of the atmosphere allowing for the perfect pressures and concentration of elements to sustain a life giving breath, to the perfect replication of DNA within billions of cells throughout the body. I’m not trying to get religious, and, no, I can’t prove this through the scientific method . . . But, if the Big Bang started the universe, what started the Big Bang? Where did the first atom or molecule or particle of dust come from? I have a very difficult time accepting that you and I are here by accident, by a chaotic explosion that created order. That implies that there must be a plan, and that plan had to have been set in motion by a Creator. That also implies that that Creator placed solutions to our challenges, including the diseases of civilization, within our grasp and available to those seeking the solutions upon the earth today.
I have seen enough in my medical career to know that simple coincidence has frequently become significantly important, life changing and often life saving. This does not happen by accident and screams loud and clear that there is a plan for you and me. No good father would lock his child in a room without doors or windows or any escape without everything in the room, both good and bad, pointing to the reason the child was in the room, and pointing the way for the child to become his or her best self, physically and emotionally. Life has meaning. It is supposed to. If we get off track, coincidence and interactions lead us back.
“Behold, the hour cometh, yea, is now come, that ye shall be scattered, every man to his own, and shall leave me alone: and yet I am not alone because the Father is with me.” (John 16:32)
The Bible, among other records, records the voices of men and women from years past transcribing their experiences with the Hand of Providence, how that spiritual void was filled, how it helped the with choice and how our lives have deeper meaning and consequence, even amidst significant adversity.
Take a week and look at the synchronicity of your life. Journal about it. Don’t dismiss a second invitation from someone to discuss an opportunity or meet someone your friend thinks could be important to you, open that book that someone left behind on the subway seat beside you. Don’t assume it is meaningless, that some kind person returned your sunglasses or your wallet. Look at the simple interactions and recent relationships. These are the breadcrumbs and the street signs from a loving Creator, a loving Father.
Keeping it real means nothing less than complete authenticity. The last place you want to be is in the first-class seat on the plane to no-where. Have the faith to get off the plane and take the bus, ride your bike, or even swim upstream in the direction you’re supposed to be going. Look for the coincidences, bread crumbs and spiritual street signs in your life.
How does this relate to a ketogenic lifestyle? Every religion or spiritual tradition speaks of a polestar. The polestar is that anchor to which the entire solar system is tied by invisible aerial chords and the engine that powers the universe. Those cords are connected with our own individual polestars. A ketogenic lifestyle is one that encompasses mind, body and spirit. It is a lifestyle that demands that you link and align your personal polestar with the truth inside and around you. It takes both courage and faith, but it brings immeasurable strength and help in achieving your goals. A person out of balance with life is under stress. Chronic stress produces excessive cortisol and other powerful adrenal hormones that displace the body’s and the mind’s endocrinologic balance, leading to weight gain, weight retention, and chronic disease. This often has significant effect externally on the body in processes seen like depression, anxiety, fibromyalgia, and allowing for amplification of inflammation and auto-immune dysfunction. We refer to this inter-relationship in the medical community as psychosomatic and/or viscerosomatic dysfunction, the psyche (the mind) and/or the viscera (internal endocrine organs) directly and adversely influence the function of the soma (the structural body separate from the mind).
“He who does not know himself, does not know anything, but he who knows himself, knows the depth of all things.
” . . . If you bring forth what is within you, what you bring forth will save you. If you do not bring forth what is within you, what you do not bring forth will destroy you.” (Book of Thomas the Contender)
Point of Focus: Your life is never without meaning. Keep it real by recognizing that diet alone may not compete your answer for physical health. Having courage and faith allow you to see and embrace the truth that is right in front of you. The Alcoholics Anonymous’ 12 step program only becomes successful when one realistically and courageously applies their faith to align with the truth they have felt all along. For any long-term lifestyle change to take place, one must connect and live the principles before one truly knows they are true. In this way the Ketogenic Lifestyle becomes real.
KetoOS – Drinkable Exogenous Ketones
LIFESTYLE PRINCIPLE 3 – TO cheat, or NOT to cheat, that is the question
I have been asked this question by every patient I have placed on a ketogenic diet at least once and often three or four times throughout the course of our treatment plan. I usually answer this question with a question. “Why do you want to cheat?”
The desire to cheat usually arises form one of three reasons:
You’re not eating enough fat to satiate your appetite and you are truly hungry. The body recognizes that it can use and absorb glucose much faster than fat, as fuel, so it naturally will crave “sweets.” In this case, the case of true hunger, solution is to increase your fat intake. You should be eating at least 50% of your total calories in the form of fat.
Insulin loads are still high, stimulating rebound hunger and hedonistic cravings. You’re either eating too many carbohydrates with your diet or you’re using a sweetener that stimulates insulin without raising blood sugar (See my article The Skinny about Sweeteners).
Cheating with a specific food fulfills a psychological need, feeds an addiction or represents an obligation to fulfill a societal ritual. Journaling helps to identify and break this cycle.
If you are truly in ketosis the cravings to cheat don’t exist, they actually disappear. Other societal rituals, like birthdays, anniversaries, weddings, spiritual ceremonies or rites of passage are often tied to or use food as symbolism. In these cases, the decision to cheat is really yours.
When a person cheats, it can take as many as 3-5 days to get back into ketosis, and for some 2-3 weeks. Carbohydrate cravings will rebound and often be present for up to 72 hours after cheating. You have to decide if cheating is worth 3 days of carbohydrate cravings and 3-7 days of stifled weight loss.
Point of Focus: There are no Ketosis Police! Really. They don’t exist! Dr. Nally will not show up in uniform on your doorstep with a set of handcuffs and a bag of pork rinds. You won’t be arrested for eating bread and those of us who have been following a strict ketogenic lifestyle for years really don don’t mind at all if you decide to cheat. We will smile and we may even ask you how it tastes or if you liked the flavor, but don’t be self-conscious, because when one is in ketosis for a few months, we really don’t crave cheating any longer, and we won’t judge you. And, don’t feel obligated to justify why your cheating, this is a lifestyle. You probably won’t ask me why I chose to wear long sleeves on a hot day in Arizona, for the same reason I won’t ask you why you decided to wear a Speedo.
LIFESTYLE PRINCIPLE 4 – Hunger Management
Life comes at you pretty fast and if you’re not prepared, hunger can bite you. Most people fall off the wagon when they are unprepared for missing a meal on a stressful day. I’ve recently heard the argument that “there is no wagon, so don’t worry about falling off.” This is false security that leaves one unprepared for life events. Pioneers traveled in wagons for two reasons. First, the wagon held supplies essential for survival. Second, wagons usually traveled in wagon trains. This means that there was more than one person on the wagon and there was more than one wagon on the trail with you. Traveling with a wagon train meant you had others on the same trail with the same tools for safety and support.
In the world of fast foot, fast photos and speedy delivery, we often don’t adequately prepare for hunger or cravings. There are some essential hunger management tools for the Ketogenic Lifestyle:
Eat meals containing >50% fat. This, in and of itself, delays hunger and ensures the satiety center of the brain is happy for longer periods of time.
Carry rescue foods with you or keep them at your office or in your fridge at home. These include low-carb nuts like almonds, walnuts, macadamia nuts; Keep hard and string cheese handy for a snack. Use sliced deli-meats with the cheese as a snack when the cravings kick in. Pork Rinds, beef jerky, olives, are great natural food options.
If you have time and can cook, develop your favorite “Fat Bombs“ and have a bag full in the fridge for those cravings.
Having the moral support of a buddy, spouse, friend or work companion who checks on your progress daily, assists with meals and meal choices is priceless. Periscope, a free Twitter based App, has become a means of checking in with your Ketogenic Support group around the world that connects to those you follow on Twitter. You can follow me, @docmuscles, and a number of fascinating health Periscopes that focus on ketogenic, low-carb, whole food paleo approaches: @livinlowcarbman, @_danielleeaton, @kasandrinos, @fatissmartfuel, @domskitchen, @mikemutzel, @keribrewster, @tombilyeu, @glutenfreenj, @paleocomfort.
Being accountable to yourself in a diet journal daily and to your doctor regularly every 1-2 months also helps keep motivation going forward. Jimmy Moore, author and podcaster at the Livin’ La Vida Low-Carb Show has also posted one of the most extensive lists of physicians specializing in ketogenic diets from around the world. You can find that list here.
LIFESTYLE PRINCIPLE 5 – Stress Reduction
Pages and pages can be written about stress reduction. In fact, I’ve written about the chemical responses that stress has on weight gain in my post, Stress. . . The Weight Loss Killer. But there are a few daily essentials that should be added into the Ketogenic Lifestyle to manage stress.
First, are you getting adequate sleep? Remove the television, computer, cell phone, iPad or other electronic distraction from the bedroom. Go to bed at the same time and get up at the same time each day. Give yourself time each day away from being plugged in, logged in or on-line.
Second, over exercising or being malnourished can cause chronic stress. I have a number of patient that have been convinced that they have to work out 60 minutes a day 6-7 days per week. It is essential that you realize muscles need a minimum of 48-72 hours to recover from specific types of exercise. If you run for 60 minutes. It will take your muscles 48 hours to recover from the running. If you do upper body weight lifting, it will take 48-72 hours for those muscles to recover from that weight lifting. Exercising the same muscle group with the same exercise over stresses the muscles and leads to significant chronic stress, spiking the cortisol levels and halting weight loss and raising cholesterol & triglycerides. Under eating or fasting to starvation has the same effect.
Third, mild intensity (40% of your maximal exertion level) exercise 2-3 days a week was found in a recent study to lower cortisol and decrease over-all stress, raising serotonin and dopamine in the brain; however, moderate intensity (60% of your maximal exertion level) to high intensity (80% of your maximal exertion level) exercise was found to raise it. A simple 20 minute walk, 2-3 times per week is very effective at stress reduction, reduction in cortisol and improvement in ketosis.
Point of Focus: The goal is cortisol reduction. This can be done through regular and restful sleep and mild exercise. Chronic elevation in cortisol directly stimulates an increase in insulin by increasing the production of glucose in the body, and cortisol blockaids the thyroid axis. Both of these actions halt the ability to loose weight, amplifies the production of inflammatory hormones and drives weight gain. Cortisol also increases appetite. That’s why many people get significant food cravings when they are under stress (“stress eaters”). Cortisol also indirectly affects the other neuro-hormones of the brain including CRH (corticotrophin releasing hormone), leptin, and neuropeptide Y (NPY). High levels of NPY and CRH and reduced levels of leptin have also been shown to stimulate appetite.
Hopefully, this gives you some starting points and direction to your Ketogenic Lifestyle. If I’ve missed something that you’ve found to be essential, let me know. Its always great to hear what has helped you in your Ketogenic journey. Until next time, pass the butter!!!
